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E2S'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
,tha,, have acertificate of consent to self 76A667A
tificatof Workers' Compensation Insurance, CE 817(REV. 8/86)
or a certified copy thereof (Sec. 3800, Lab. C.)
r COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.t Xff JK Company 5//U& Fiel-
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p
Certified copy is filed with the county building inspec- ADDRESS -/0 1 0,
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
145 C/ C .
DateWATER CLOSET 0
Appli4anl NEAREST'•.
CERTIFICATE OF EXEMPTION FROM RKERS' BATH TUB i) CROSS ST` ;f74r J2 li;- jA
COMPENSATION INSURANCE SHOWER v OWNER
.(This section need not be completed if the work involved by MAIL Vh
the permit is for one hundred dollars($100)or less.) LAVATORY l V ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. -513 a
so as to become subject to the Workers'Compensation Laws. DISHWASHER � f
CONTRACTOR ® �
Date Applicant CLOTHES WASHER If
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS A/2,,
f G� AMC,
Exemption, you should become subject to the Workers' CITY EL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �� - Cou�� a
with comply with such provisions or this permit shall be STATE LIC. !�
deemed revoked. WATER HEATER LICENSE NO. `� CLASS i�
LICENSED CONTRACTORS DECLARATION DISTRICT�O. (/ CESSED BY
U
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /1 g
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ) (1 iJ
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALc/ VA DATION
$ .
License Number J Lic. Class_
FI
Contractor Date .�
Z��k to
�9
❑ I am exempt nder Sec.
B.&P.C. for this reason
Plan check fee
Date: !l
PLUMBING PERMIT ISSUING FEE$ (/ z b 7 0.7-A
Signature '
TOTAL FEE
# 000ao5
Plan check applicant
SINGLE FAMILY ( o o 58.5 0
HOME OWNER-BUILDER DECLARATION Name
I hereby offirm that I,om exempt from the Contractor's License o -
Address 58,5050
Law for.the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. 0 x 2 0-8 7
❑ I, as owner of the property,. will do the work and the
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nome
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me i ed o erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Per mi ee E5ote